Cardiovascular complications of recreational cocaine use in pregnancy: myth or reality?

This preliminary trial suggests that tablet methergine can be successfully used to relieve PDPH in postcesarean section patients.

Abstract

Sir, Cocaine intake by the parturient has been linked to a number of obstetrical and obstetrical anesthesia emergencies (1). I herein report a case of a parturient who required administration of general anesthesia to manage crack cocaine-induced hemodynamic instability that occurred intraoperatively (cesarean section) following delivery of a healthy fetus under spinal anesthesia. A 21-year-old, 171 cm, 69 kg, gravida 1, para 0, otherwise healthy female with a history of recreational crack cocaine intake (including in pregnancy) at 39.5 weeks of gestation and in labor required emergency cesarean section for fetal malpresentation (frank breech presentation). She reported no known drug allergies and no history of prior anesthesia. The course of her pregnancy had been uneventful; however, she admitted to recreational (daily) crack cocaine intake, including on the day of delivery (3 h prior to admission). Her admission blood pressure was 125/75 mmHg, heart rate 75 beats/min and respiratory rate 18 breaths/min. Fetal heart rate was 140 beats/min and reactive. The patient appeared slightly intoxicated but cooperative. An intravenous fluid preload with crystalloid solution was initiated and the patient was taken to the operating room. A T4 sensory level of spinal anesthesia was established with 12 mg of 0.75% bupivacaine, 5 µg of fentanyl and 0.2 mg of morphine, and surgery began. Shortly after delivering the fetus and placenta, the patient suddenly developed bradyarrhythmias, ST-segment depression (3 mm) and hypotension. Induction of general anesthesia, endotracheal intubation, intravenous atropine and phenylephrine were required to restore stability. Surgery was promptly completed and patient was extubated in the operating room. No further cardiovascular events were recorded and her postpartum course remained uneventful. Serial phosphokinase (CPK) testing to rule out myocardial infarction was normal. A positive urine toxicology screening confirmed recent cocaine intake. Substance addiction is most often first suspected or diagnosed during medical management of another condition such as hepatitis, human immunodeficiency virus (HIV) syndrome or pregnancy. Regardless of the drug(s) ingested and clinical manifestations, it is always uniformly difficult to predict obstetrical and anesthetic implications in substance-abusing pregnant patients 1-3). Cocaine is a natural alkaloid found in the leaves of the Erythroxylon coca plant, indigenous to Peru, Ecuador and Bolivia. The prevalence of cocaine abuse in young women has increased significantly over the past 25 years (1). It has been estimated that 90% of cocaine-abusing women are of childbearing age. The ingestion of cocaine produces prolonged central and peripheral adrenergic stimulation by blocking the presynaptic reuptake of sympathomimetic neurotransmitters, including norepinephrine, dopamine and serotonin. Crack is an almost pure form of cocaine. Today, this alkalinized form of cocaine is smoked widely throughout the world (1). By the 1990s highly additive crack cocaine became the most widely abused illicit substance in the United States. Five million Americans are regular abusers of cocaine, 6000 use the drug for the first time each day and more than 30 million have tried cocaine at least once (1). The typical cocaine-abusing parturient does not fit into any specific socioeconomic, ethnic or cultural profile. Associated risk factors that may suggest cocaine abuse in pregnancy include lack of prenatal care, history of premature labor, and cigarette smoking. Most patients with a history of cocaine abuse deny it when interviewed preoperatively by primary care physicians, obstetricians and anesthesiologists 1-3). Pregnancy is known to enhance the cardiovascular toxicity of cocaine. Acute cocaine intake has been associated with obstetrical emergencies such as placental abruption and fetal distress. Maternal cocaine use is associated with adverse events in nearly every organ system. Cardiovascular complications account for most cocaine-related maternal deaths. Cardiovascular complications of cocaine intake include blood pressure liability (either hypo- or hypertension), tachyarrhythmias, hemorrhagic and ischemic stroke, aortic dissection, cardiomyopathy, accelerated coronary artery disease, myocardial ischemia, myocardial infarction, and sudden cardiac death. However, cocaine-induced bradyarrhythmias have been scarcely mentioned (4). I am not aware of any reports documenting emergent, intrapartum (intraoperative) management of a parturient with cocaine-induced bradyarrhythmias and transient myocardial ischemia. In conclusion, obstetricians and obstetric anesthesiologists should be aware of this association when providing care to cocaine-abusing parturients.